Provider Demographics
NPI:1528599842
Name:MIRACLE WANDS CLINIC
Entity Type:Organization
Organization Name:MIRACLE WANDS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-271-5925
Mailing Address - Street 1:1143 STORY RD STE 250&260
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-2610
Mailing Address - Country:US
Mailing Address - Phone:408-899-2254
Mailing Address - Fax:
Practice Address - Street 1:1143 STORY RD STE 250&260
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-2610
Practice Address - Country:US
Practice Address - Phone:408-899-2254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54418261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center